NIH HEAL Initiative and Helping to End Addiction Long-term are service marks of the U.S. Department of Health and Human Services.

Structural Racism as a Key Determinant of Substance Use Outcomes

Hillary Kunins, MD, MPH, MSWednesday, September 9, 2020

Key Take Aways: Structural racism leads to adverse drug control policies and treatment practices, and worse substance use outcomes1. Structural racism is a key determinant of adverse health and social outcomes among people who use drugs.

2. Among the effects of structural racism are drug control policies that worsen outcomes from substance use

3. Need an explicit antiracist approach to research, program, and policy to speed scientific and equitable solutions to the national opioid (and other drugs) public health crisis

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Structural racism defined

• The totality of ways in which societies foster racial discrimination, through mutually reinforcing inequitable systems:

− Housing, education, employment, earnings, benefits, credit, health care, criminal justice

• These systems reinforce discriminatory practices and distribution of resources, which together affect health outcomes.

3Bailey ZD, Krieger N, Ageor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463.

Shifting overdose demographics • As the face of the heroin epidemic perceived to be a

white problem, new mantra:o “We can’t arrest our way out of the problem.”

• In New York City, overdose deaths among Black New Yorkers increased in 2017, exceeding rates among white New Yorkers

• Without addressing the structural racism that undergirds the overdose epidemic in Black, indigenous and communities of color, punitive approaches again become normative (not that they have stopped)

4Allen, B et al. Racial Differences in Opioid Overdose Deaths in New York City, 2017. JAMA Internal Med 2019; 179(4): 576-578.

Example 1: Criminalization of Black people during “War on Drugs” to present

• Key drug laws heightened punishmento New York State Rockefeller Drug Laws of 1973 spread

nationally (mandatory sentencing)o Anti-Drug Abuse Act of 1986 (more severe criminal

penalties for solid vs powder cocaine)

• Discriminatory enforcement of drug laws by race

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Csete J, Kamarulzaman A, Kazatchkine M, et al. Public health and international drug policy. Lancet, 2016; 387 (10026): 1427-1480.Drucker E. Population impact of mass incarceration under New York's Rockefeller drug laws: an analysis of years of life lost. J Urban Health 2002; 79(3):434-5.Saxe Walker L, Mezuk B. Mandatory minimum sentencing policies and cocaine use in the U.S., 1985-2013. BMC Int Health Hum Rights 2018; 18(1):43.

Similar proportions of drug use among Blacks and whites; disproportionate drug-related arrests and incarceration

6Available at: https://www.hamiltonproject.org/charts/rates_of_drug_use_and_sales_by_race_rates_of_drug_related_criminal_justice; October 21, 2016

Consequences of drug use mediated through inequitably-applied criminal justice and social service policies• Criminal justice and social service policies cause health

and social harmso E.G.: Criminal justice history may preclude access

to housing; housing associated with better substance use outcomes

• Discriminatory enforcement of drug laws by race causes the drug use consequences to vary by race

Consequences of drug use mediated through inequitably-applied criminal justice and social service policies

“Imagine you are Erma Faye Stewart, a 30-year old African American single mother of two. You are arrested as part of a drug sweep in Texas. You spend a week in jail, you have no one to care for your children and are eager to get home. Your court-appointed lawyer urges you to plead guilty to distribution, saying the prosecutor has offered probation. You refuse, steadfastly proclaiming innocence. After a month in jail, you decide to plead guilty so you can return home to your children. Unwilling to risk trial and years of imprisonment, you are sentenced to 10-years probation, $1,000 fine, as well as court costs. You are now branded a drug felon. You are no longer eligible for food stamps, you may be discriminated against in employment; you cannot vote for 12-years; and you are about to be evicted from public housing. Once homeless, your children will be taken from you and put in foster care."

Alexander M. The New Jim Crow, The New Press: New York, NY, 2010.

Example 2: Inequitable access to effective treatment for opioid use disorder• Buprenorphine was the second FDA-approved drug for

opioid use disorder since methadone• Inequitable availability of buprenorphine treatment for

white and wealthy people resulted from racially targeted marketing strategies and inadequate insurance reimbursement

• Flexibility and privacy afforded by buprenorphine (compared to methadone) less available to people of color

• Opportunity for social integration and employment diminished by restrictive access to more flexible treatment (needs study)

9Netherland J, Hansen H. Biosocieties. 2017; 12(2):217-238; Hansen HB, Siegel CE, Case BG, et al, J Behav Health Serv Res 2013; 40(3):367-377.

Example 3: Judicious opioid prescribing applied inequitably

• Opioid analgesic prescribing is an appropriate focus to decrease overdose deaths

• Reconsideration of prescribing practices underway• Prior studies:

o Black and other patients of color less likely to be prescribed effective pain medications

• Emerging evidence:o Black patients receive disparate opioid monitoring, tapering

and discontinuation Opioid discontinuation for Black patients 2.1 and 3.3 times more likely

than white patients because of cannabis or cocaine use respectively Opioid dose reduction among Black patients more likely during pain

treatment compared to white patients• Need to undo racist application of prescribing policy and

continuously assess impact of policy change by race

10Gaither JR, Gordon K, Crystal S et al. Drug Alcohol Depend 2018; 192:371-376.

Buonora M, Perez HR, Heo M, Cunningham CO, Starrels JL. Pain Med. 2019; 20(8):1519-1527.

Conclusions• Consequences of structural racism against

people of color have perpetuated punitive approaches and diminished the effectiveness of public health-oriented approaches to drugs

• We will reproduce structural racism without deliberate anti-racist practice

• Need an explicit anti-racist public health approach to advance science and create equitable outcomes in the national overdose crisis

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Thank you

Tools for antiracist public health practice• Develop and assess programs that are place-

based, multisector, and explicitly address racial equity

• Prioritize policy reform: change policies that adversely and disproportionately affect Black and other people of color

• Study and correct differential impact of policy and practice on Black and other people of color

13Kunins, HV. Structural Racism and the Opioid Overdose Epidemic: The Need for Antiracist Public Health Practice, Journal of Public Health Management and Practice, 2020; 26 (3):201-205